Kingwood Pines Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights as evidenced by the facility’s failure to ensure that the health and safety of patients were protected by providing care in a safe setting. The potential risks that were identified included ligature anchor points in bathrooms. More specifically, A) The facility failed to ensure that the bathrooms in the Intake Department had no ligature anchor points. Patients being processed for admission were allowed to use the hallway bathrooms as were patients in the cafeteria and the gymnasium. A female patient with suicidal ideation was observed going into the male bathroom alone. A male Admissions Coordinator stood in the hallway, waiting for the patient. It had been noted just prior to this incident, that the stall doors (two in the female bathroom and one in the male bathroom) had ligature anchor points at the top hinge. These ligature anchor points had been identified by the facility five years earlier. See A-0144 Patient Rights - Care in a Safe Setting. B) The facility failed to ensure that the shower in the bathroom of room 510 had no ligature anchor points. A metal track for hanging shower curtains was not flush to the top of the shower compartment, creating a gap that could be used as a ligature anchor point for self-harm as was demonstrated by a staff member. See A-0144 Patient Rights - Care in a Safe Setting. Collectively, these potential risks put all patients throughout the hospital at risk for the likelihood of harm, serious injury, and possible death. Additionally, C) The facility failed to ensure that the Intake Department took into consideration a patient’s very recent history of sexual aggression. During a previous admission, Patient #4 was placed on sexually aggressive precautions after she became inappropriate with her roommate. Patient #4 was discharged and re-admitted into the same facility two days later, at which point, she was placed in a shared room with Patient #7. Patient #4 was then sexually inappropriate with Patient #7. See A-0144 Patient Rights - Care in a Safe Setting. .”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to provide privacy during personal hygiene activities such as toileting, showering, and dressing. This was evidenced by the privacy and/or shower curtains missing in 5 of 32 bathrooms (rooms 114, 208, 212, 213, and 411). (The privacy curtain is the curtain that separates the bedroom from the bathroom.) Findings were: Record review of policy 16799019, “Patient Rights, PR-109,” Patient Rights Area, last approved 11.2025, showed: “Delineation of Patient Rights ... C. The right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs and promotes respect and dignity for each individual.” Observation of the bathrooms throughout the facility on 2.25.2026 at 11:30am showed five bathrooms with missing privacy and/or shower curtains. Room 114 - missing both privacy and shower curtain. Room 208 - missing privacy curtain. Room 212 - privacy curtain hanging by one clip making it useless. Room 213 - missing privacy curtain. Room 411 - missing both privacy and shower curtain. In an interview with Staff C (ACNO) during the tour, she stated that a work order had been put in for the bathroom and shower curtains missing in room 411. When Staff P (Unit 400 RN) made a phone call, she found that a work order had not been put in and promptly did so. Staff C (ACNO) stated that each bedroom should have a privacy curtain as the door to the bathroom and that there should also be a shower curtain, adding that this was a patient’s right issue. .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to provide care in an environment that a reasonable person would consider to be safe. More specifically, the facility failed to ensure that patients were provided care in a safe setting. This failure was evidenced by: A) The facility failed to ensure that the bathrooms in the Intake Department had no ligature anchor points. The stall doors (two in the female bathroom and one in the male bathroom) had ligature anchor points at the top hinge. Patients being processed for admission and patients in the cafeteria and the gymnasium were allowed to use this bathroom. B) The facility failed to ensure that the shower in the bathroom of room 510 had no ligature anchor points. A metal track for hanging shower curtains was not installed flush to the top of the shower compartment on one end, creating a gap that could be used as a ligature anchor point. C) The facility failed to ensure that the Intake Department took into consideration a patient’s recent sexually aggressive behavior during the admission process. This failure was evidenced by: 1. Patient #4 had a very recent history of being on sexual aggression precautions while hospitalized in the same facility, after being sexually inappropriate with her roommate, and; 2. Instead being placed in of a blocked room during her readmssion into facility two days after being discharged, Patient #4 was placed in a shared room with Patient #7. Patient #4 was then sexually inappropriate with Patient #7. Findings were: A) Staff door hinges with ligature anchor points. Record review of the Ligature Risk Assessment revised 10.30.2025 by Staff Y (Director of Plant Operations - DPO) showed: “Lobby and Assessment Bathrooms ... Hinges in bathrooms ... Privacy doors on stalls are non-compliant and a ligature point. 5.29.2020 ... privacy stalls will be part of a budgetary project. Target Date: July 05.” Observation on 2.25.2026 at 1:00pm showed two bathrooms - one male and one female - located across from the Intake Department and gymnasium and adjacent to the cafeteria. Further inspection of the men’s bathroom showed a ligature anchor point at the top and bottom hinges of the stall door. Two stalls with ligature anchor points on the top and bottom hinges were found in the women’s bathroom. Record review of the High-Risk Notification Alert dated 2.24.2026 at 5:08pm for Patient #12 showed a 14-year-old female being admitted to Unit 600, a female adolescent unit. High-risk factors included: auditory and visual hallucinations, suicidal ideation with a previous suicide attempt December 2025, self-harm - scratching self - self-injurious behaviors, and an elopement risk. Record review of Ancillary Orders by Staff W (Admitting MD) dated 2.24.2026 at 5:00pm showed Suicide Precautions. Record review of the SBAR (Situation, Background, Assessment, Recommendation) dated 2.24.2026 at 5:21pm (estimated time of arrival to the unit) showed: High-Risk Areas - Suicide, Elopement, Medical Complications, SELF-HARM RISK, and self-injury precautions. Chief Complaint: Transfer from Burke Center with suicidal ideation. She was described as angry and had been scratching herself. She stated she could not control the intrusive thoughts which were becoming “more severe than the thoughts that led [to] her suicide attempt by overdose in December 2025.” She was triggered by a breakup with her boyfriend and “has not been able to cope.” She endorsed auditory and visual hallucinations, stating she “vividly saw a bear and hears banging against the wall and random people calling her name.” Observations on 2.24.2026 at 10:55am showed Staff O (Admission Coordinator) was standing in the hallway. When the surveyor attempted to enter the men’s bathroom, he was stopped by Staff O. In an interview with Staff O, he stated that a patient was in the men’s bathroom because the women’s bathroom was being cleaned. About a minute later a female patient, later identified as Patient #12, exited the bathroom and returned to the Intake Department with Staff O. In an interview with Staff O on 2.25.2026 at 9:47am, he stated that he does “outside monitoring” on patients in the restroom, adding, “I don’t go into the bathroom with the patient. If the patient is a high-high risk, I may keep the door open and will knock on the door every 1 to 1½ minutes.” B) Metal shower curtain track with a ligature anchor point. Record review of the Ligature Risk Assessment revised 10.30.2025 by Staff Y (Director of Plant Operations - DPO) showed: “Patient Bathrooms ... No features in the bathrooms provide an opportunity for hanging. Pick proof caulk is utilized to fill gaps and crevices.” Observation of the one-piece shower stall in room 510 on 2.24.2026 at 11:30am showed a metal shower curtain track that was no longer in use. One end of the track was not flush to the top of the stall, creating a ligature anchor point. Staff C (ACNO) demonstrated how a piece of fabric could be wedged into the gap and used for hanging self or strangulation. In an interview with Staff C (ACNO) during the observation, she stated that the metal shower curtain track created a ligature anchor point. . 38015 C. Intake department not recognizing sexually aggressive patient and placing this patient in a shared room: Review of facility policy #19268439 last revised 5/23 titled “Room Assignment”, AD-107 showed that patients would be assigned rooms based on precautions or other clinical needs. Review of facility policy #16821236 last revised 8/19 titled “Precautions, PC 190” showed that all patients would be assessed at admission for any history of sexual aggressive behavior. It also showed that considerations for room assignments shall utilize assessment information, including sexual aggression, sexual behaviors, and verbalization on unit, and that room assignments would also be considered if patients had homosexual preferences. Record review of Patient #4’s clinical chart showed the following: 11-year-old female who identified as homosexual was admitted to the facility on 8/18/26 due to depression, anxiety, and obsessive intrusive thoughts. On 8/22/26, she asked her roommate, Patient #8, to have sex with her. This generated an incident report and her doctor, MD Staff #H, put her on sexual aggression precautions and placed her in a blocked room by herself to keep other patients safe. Patient #4 was then discharged from facility on 8/25/26. On 8/27/26, two days later, Patient #4 was readmitted to facility, again under MD Staff #H, after she had a “meltdown” and “rage” and was physically aggressive with staff and peers at her group home. The initial nursing intake assessment did not recognize the patient’s recent past history of sexual aggression. She was not flagged as high risk for sexual aggression, and there were no physician orders for her to be on sexual aggression precautions. In addition, there were orders for routine close observation rounding every 15 minutes. She was placed in a shared room with Patient #7. On 8/30/26, Patient #4 said inappropriate sexual comments to her roommate while trying to unzip her pants per facility incident report; the patient also undressed in front of her roommate per incident report. Patient #4 was then put in a blocked room, placed on sexual aggression precautions, and close observation rounding every 5 minutes until her discharge on 9/2/26. In an interview on 2/26/26 at 2:00 pm, CEO Staff #A stated the following: when the patient was readmitted on 8/27/26, she should have been put in a blocked room, placed on sexual aggression precautions and been on close observations rounding every 5 minutes. Staff #A added that this was an oversight of the facility’s process and should have been caught and addressed starting in admission. .”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure supervision of nursing care for sexual aggression monitoring was carried out for 1 of 1 patients (Patient #3) as shown by: 1a. numerous close observation rounds that should have been conducted every 5 minutes per doctor’s orders were not performed, as evidenced by numerous missing entries on the close observation documentation forms, 1b. these close observation documentation forms were not dated, making it impossible to discern what days the rounding took place, and; 2. Orders for sexual aggression precautions, which were physician orders, were not noted on the facility’s primary Special Precautions documents or the close observation every 5 minutes rounding sheets, indicating the patient was on these precautions. Findings included: Review of facility policy #18806427 last revised 8/25 titled “Patient Observation Rounds, PC-125”, which stated its purpose was to provide a process for observing and documenting patient’s location and behavior, showed the following: The MHT or Nurse will conduct and document rounds concurrently so that round sheets do not contain late or missing entries. It also showed that it was the nurse and MHT who were responsible for ensuring each form accurately reflected the precaution(s) levels and current high risk indicators. It also showed that documentation should be done during the completion of rounds. Record review of Patient #3’s clinical chart showed the following: 33-year-old female involuntarily admitted to facility 2/5/26 due to history of assaulting boyfriend and police, history of four suicide attempts, homicidal ideation, aggression, delusional. Diagnoses included Schizoaffective disorder, bipolar type. The patient was still residing in facility at time of survey. Per facility incident report log, the patient was involved in several sexual boundary incidents, including on 2/12/26, 2/13/26, 2/16/26, and sexual assault 2/19/26. Psychiatric progress notes from NP-Staff #E included the following: 2/10/26-Patient with very poor personal boundaries. 2/12/26- Patient disrobing, running around naked, sexually inappropriate, saying she wants somebody to come and have sex with her. 2/17/26-Patient attacking peer, aggressive and “very sexually inappropriate behavior and language”. Nursing notes dated 2/19/26 at 12:35 pm showed that patient told an MHT that while she was asleep, a male peer came inside her room (Patient #6), exposed himself, and had vaginal intercourse with her. She was laying on her stomach and the peer laid on top of her. The peer was transferred to another room and the patient was placed on ‘Q’ (every) 5 minutes close observations. Physician orders from MD Staff #G on 2/19/26 at 2:00 pm showed the patient was placed on sexual aggression precautions and Q 5 minutes close observations rounds. On 2/20/26 Patient #3 was sent to Memorial Herman Northeast Hospital for a sexual assault exam (SANE), treated with antibiotics, and returned to the facility. In an interview on 2/24/26 at 1:45 pm, DRM-Staff #F stated he conducted an investigation but could not confirm an assault had occurred because patient was not a good historian due to her acute mental illness, and, there was ketchup on the video lenses, blocking full views of the video surveillance. Further review of the Patient #3’s clinical records showed: Close observation rounds documentation conducted every 5 minutes per doctor’s orders. However, there were large segments of time on the documentation forms where observations were not performed/documented, ranging from an hour to several hours, for every day after 2/19/26. In addition, none of these forms were dated, making it impossible to know what days the rounding occurred. There were also forms titled “Patient Observation Record & Milieu Group”. These forms contained all the types of “Special Precautions” of physician orders for staff to follow through. They included the following precautions: Sexual Victimization, Sexual Aggression, Suicide, Aggression, Elopement, Medical Risks, Seizures, Detox, Assault, Fall Risk, Self Harm, Assault Victim, Homicide, Other. However, neither these forms or the close observation every 5 minutes indicated the patient was on sexual aggression precautions. In an interview on 2/24/26 at 2:15 pm with ACNO Staff #C and CNO Staff #B, both acknowledged the patient should have had every close observations every 5 minutes documented on these forms, after seeing the numerous missing times of observation. In addition, they stated the sheets should have been dated, and, staff had been using wrong forms. In addition, they both stated the Patient Observation Record & Milieu Group forms should have listed sexual aggression as one of the precautions after they were ordered on 2/19/26.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 38015 Based on observation and interview, the facility’s infection prevention and control program failed to adequately ensure a clean and sanitary environment as shown by the presence of a patient mattress with large tears in use for multiple patients. Findings included: Observation on 2/25/26 at 11:55 am of adolescent female unit #600 showed that in Room #208, there was a plastic mattress with a vertical tear, approximately three feet long and an inch wide, plus several other parallel vertical tears posing an infection control risk. This mattress was in use by a previous patient and was going to be used by another patient admitted to the same bed. In an interview at the time of findings, ACNO-Staff #C acknowledged the infection control issue and had the mattress removed.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 43549 Based on record review and interview the facility failed to assure medical record entries were completed for 1 of 3 patients with assessments provided by NP #25. Nurse Practioner (NP) #25 failed to complete documentation of assessments. There was no date, time, signature or credentials for 1 of 3 patients trviewed with assessments provided by NP #25. Patient #S had a Medical Consultation Note filed in the chart between 11/1/25 and 11/3/25. The consultation was filled out but lacked a date, time, signature and credentials. The handwriting on the form matched documentation made 11/1/25 by NP #25. Physician #29 was called 12/4/25 at 4:10 PM and questioned regarding who did consultations for her. She confirmed NP #25 was the sole agent who assisted her at this facility. When interviewed 12/4/25 at 4:20 PM administrative staff #19 confirmed the Medical Consultation Note filed in the chart between 11/1/25 and 11/3/25. The consultation was filled out but lacked a signature, credentials, time and date and was filled out but lacked a signature, credentials, time and date.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights as evidenced by failure to ensure male adolescent patients and staff members were provided a safe environment. More specifically: A) The facility failed to ensure 3 of 3 male adolescents (Patients #1, #2, and #3) and Staff F (MHT) were provided a safe setting. Staff F, a MHT, went into the bedroom of Patients #1 and #2 alone with no backup to separate them as roommates. The two patients were already agitated and disrupting the unit. The request by Staff F turned into a verbal confrontation that quickly escalated into a physical altercation between the two patients and the staff member. Both patients alleged injury by Staff F. The altercation further escalated when Patients #1 and #2 followed Staff F out of the bedroom to the far end of the hallway, continuing to fight him. Available staff from across the hospital was called to the unit for assistance. It was at this point that Patient #3 interjected himself into the emergency behavioral intervention to assist hospital staff in their de-escalation of Patients #1 and #2. Patient #3 alleged an injury to his right kidney area. See A144 - Patient Rights: Care in a Safe Setting. B) The facility failed to ensure that 3 of 3 patients (Patients #1, #2, and #7) were monitored in such a way as to prevent their elopement from an outdoor space. This failure resulted in the three adolescents scaling a 9-foot fence while staff members assigned to monitor the patients were positioned in areas with obscured visualization of the patients. Additionally, a subsequent full investigation was not conducted. See A144 - Patient Rights: Care in a Safe Setting. C) The facility failed to provide an environmentally safe outdoor space for patients on a fresh air break as evidenced by: 1. The presence of at least three large potential splinters of wood on the wooden fence planks available for patients to break off and use for harm to others or self-harm, and 2. The presence of at least two large rusty nails protruding from the wood on the fence. See A144 - Patient Rights: Care in a Safe Setting. .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35028 . Based on observation, interview, and record review, the facility failed to ensure that 4 of 4 male adolescent patients (Patient #1, #2, #3 and Patient #7) and Staff F (MHT) were provided a safe setting. More specifically, A. The facility failed to ensure that Patients #1 and #2 and Staff F (MHT) were protected from harm when Staff F (MHT) went by himself into the bedroom of the two patients (who were already agitated) to separate them as roommates. Additionally, the facility failed to ensure that Patient #3 was protected from harm when he interjected himself into an emergency behavioral intervention in which hospital staff were de-escalating Patient #1 and Patient #2 as they physically assaulted Staff F (MHT). Patient #3 alleged injury to his right flank area and was treated in an emergency room for hematuria [blood in the urine]. B. The facility failed to ensure that Patients #1, #2 and #7 were monitored in such a way as to prevent their elopement from an outdoor space, as well as conducting a subsequent full investigation. C. The facility failed to provide an environmentally safe outdoor space as evidenced by: (1) The presence of at least three large potential splinters of wood on the wooden fence planks available for patients to break off and use for harm to others or self-harm, and; (2) The presence of at least two large rusty nails protruding from the wood on the fence. Findings included: A. Injury of Patients #1, #2, and #3. Patient #1 Review of “Psychiatric Evaluation” by Staff P (MD), dated 6/28/25 at 7:51pm, showed: Patient #1 was a 14-year-old male in the foster care system, admitted after a “meltdown and rage” at a residential treatment center. He made “violent and homicidal threats’ toward his caregivers and eloped from the facility. Admission diagnoses: Disruptive mood dysregulation disorder; cannabis use disorder, moderate. Patient #2 Review of “Psychiatric Evaluation” by Staff P (MD), dated 6/27/25 at 10:22am, showed: 16-year-old male with constant thoughts of killing himself and attempt by hanging. He was a “danger to self [and] others” and destructive of property. Admission diagnoses: Disruptive mood dysregulation disorder; cannabis use disorder, moderate. Patient #3 Review of “Psychiatric Evaluation” by Staff P (MD), dated 6/6/25 at 8:10am, showed: 16-year-old male admitted with hallucinations, delusions, agitation, anxiety, depression, danger to self and others, and substance use. He had damaged the house and threatened his father with a knife. Admission diagnoses: Disruptive mood dysregulation disorder, severe cannabis use disorder, and attention deficit hyperactivity disorder. ***** The Incident. Review of the Incident Log showed an event that occurred on 7/4/25 at 10:30pm, involving Patient #1, Patient #2, and Staff F (MHT). The log showed: Staff F (MHT) went to the bedroom of Patient #1 and Patient #2. He asked Patient #1 to “stop being so loud as others were sleeping.” As he stepped into the room “another patient (Patient #2) hit from behind and shoved him and closed the door behind him.” MHT tried to “restrain” Patient #1 who was “attacking him from the front.” The nurse heard Patient #1 yell out, “You are choking me.” When the nurse entered the room, she saw Staff F “between the two boys as he was attempting to restrain patient [Patient #1]. They fell on the bed, landing on top of him.” Staff F removed himself from the room. Patient #1 had “one scratch red in color on right side of ear, one scratch to chest.” In an interview with Staff F (MHT) on 7/14/25 at 5:45pm, he stated: On 7/4/25 at around 9:00pm, Patient #1 and Patient #2 were roughhousing and loud, keeping other patient from sleeping. They were “throwing wet tissue balls.” At the direction of Staff I (Charge RN), Staff F went to the bedroom alone to move one of the boys to another room. They “refused to be separated.” Patient #1 “pushed” Staff F. While he was facing Patient #1, Patient #2 closed the bedroom door and punched him in the mouth splitting his lip. As Staff F held Patient #1 from behind, Patient #2 punched Staff F in the back of the head multiple times. Staff F and Patient #1 tripped and fell over the bed. Patient #1 yelled, “Get off me.” Staff F exited the room and went to the far end of the hallway. A “Code Green” (signals an aggressive or escalating patient situation requiring immediate intervention and de-escalation efforts) was called. As the code team from across the hospital arrived, Patient #1 and Patient #2 went to the end of the hallway to attack Staff F again. Review of video surveillance for 7/4/25, 10:15pm-10:22pm, showed: 10:15pm. Staff F (MHT) and Staff I (Charge RN) in the hallway. MHT went into the bedroom of Patients #1 and #2. The door closed behind MHT. 10:16pm. Less than one minute later, Staff I (Charge RN) ran into the same bedroom Staff F (MHT) had entered. Within seconds MHT and Charge RN come out of bedroom. Charge RN went to nurse’s station and called for help. MHT went to the far end of the hallway and sat down. He had the observation rounds clip board in his hand. 10:19pm. Patient #1, #2, and Patient #3 gather at the nurse’s station. Patient #2 got on the phone. Patients #1 and #2 start down hallway toward Staff F (MHT). Staff H (MHT) was just ahead of Patients #1 and #2. Staff H (MHT) tried to stop the two patients from going further down the hall. 10:22pm. Patients #1 and #2 physically attacked Staff F (MHT) and Staff H (MHT). Patient #3 went down the hallway toward the altercation. Patient #3 pulled Patent #2 off Staff F (MHT). Staff Y (MHT) was injured. Staff K (MHT) talked with Patient #1. For the next 5-6 minutes, Staff G (House Supervisor) had Patient #2 in a hold. In an interview with Staff G (House Supervisor) on 7/14/25 at 5:55pm, he stated he arrived at the adolescent unit for the Code Green. He helped restrain Patient #2 in the hallway. Staff F (MHT) exited the unit. Patient #1 and Patient #2 told Staff G they had been hit by Staff F. Shortly thereafter, Staff G noted Patient #2 had scratch marks on his neck that “were not there earlier.” Patient #2 also told him he did not know how the scratches got on his neck. The two patients continued to refuse to be separated. In an interview with Patient #3 on 7/10/25 at 9:48am, he stated he was punched in the right kidney area when Patient #1 and Patient #2 attacked Staff F (MHT). He also stated he tried to pull Patient #2 off Staff F and it was during this intervention that he was injured. He concluded by saying he was sent to the emergency room several days later because of blood in his urine. In an interview with Staff E (Charge RN - adolescent boys) on 7/10/25 at 10:35am, she stated that Patient #3 had complained He was “punched or elbowed” when he was pulling a patient off Staff F (MHT). She also stated she had seen blood in Patient #3’s urine, adding that the patient was sent to an emergency room for evaluation. In an interview with Staff F (MHT) on 7/14/25 at 5:45pm, he stated he saw Patient #3 “grab one of the boys that was trying to attack him.” He also stated Patient #3 should not have been a part of the code by assisting staff. In an interview with Staff G (House Supervisor) on 7/14/25 at 5:55pm, he stated Patient #3 should not have been a part of the code by assisting staff. In an interview with Staff A (CEO), Staff B (CNO), and Staff C (Quality Director) on 7/14/25 at 4:00pm, they stated Patient #3 should not have been a part of the code by assisting staff. Review of policy 16822136, “Precautions, PC 190,” last reviewed 5/2025, showed: “Response and notification plan for patients who become aggressive or make homicidal threats ... Staff will make all attempts to maintain a safe environment where patients are protected.” . 38015 . B. Monitoring patients who eloped/failing to perform full investigation: In interviews on 7/14/25 and 10:30 am, CEO Staff #A and CNO Staff #B stated that Patient #7 eloped by jumping over the fence in the adolescent playground area by himself without help and staff did not notice. They were unsure exactly when he did this because cameras could not see a blind-spot where the patient supposedly breached the fence. Patient #7 then later allegedly helped Patient #1 and Patient #2 elope over the fence, which was witnessed by staff, and a Code 5 (elopement code) was called. A full facility investigation was requested at this time but the only things presented by Staff #A, #B and #C were three written staff witness statements, two brief written patient statements, and a written video review timeline on 7/2/25 from 4:02 pm- 4:06 pm with four entries. Review of the written video timeline’s last entry showed that at 4:06 pm, the patients went into a blind spot and were captured by video surveillance anymore. It then stated that “Patient jumped the fence and elope from the hospital”. This was written by RM Staff #M. No further information was documented. Record review of Patient #7’s clinical chart showed he was a 16 year old male admitted to facility on 6/29/25 due to suicidal ideation with a history of past attempted suicide. The Columbia Suicide Severity Scale risk assessment showed the patient was high risk for suicide. Physician’s Discharge Summary notes dated 7/2/25 showed the patient eloped approximately 4:40 pm that day and had not been found. Observation on 7/14/24 at 11:00 am of facility’s two recreation areas, one adult and the other adolescent, showed there was an unlocked gate connecting them both together. CNO Staff #B and QD Staff #D, who were both present at the time, stated the patients eloped from the corner of the adolescent area but cameras did not visualize this because it was in a blind spot for the camera. Review of written witness statements showed the following: MHT Staff #O wrote that all three patients ran through an open gate and eloped: “ ...they discovered that the gate opens and they opened the gate and ran out.” RN Staff #E wrote: “I was told they went through one gate on the playground as it was not locked & climbed over the second gate.” Patient #1 wrote: “I went through the sidegate of the playground, the gate was open, and then I jump the fence by the houses.” In further interviews on 7/14/25 at 3:30 pm with Staff #A, B, and C, they were asked about the gate and stated that in the camera view of the adolescent playground where the patients allegedly eloped from, there was a blind spot and although the gate could not be visualized from the adolescent area, the camera in the adult area on the other side of the gate would have been triggered by movement and would have captured the patients coming through. However, since the cameras did not record anything, it was concluded that the patients did not come through the gate. In an interview on 7/14/25 at 3:35 pm, Staff #A stated that Patient #7’s whereabouts was still unknown. C. Safe environment: Wooden splinters and rusty nails: Findings included: Review of facility policy #16821276 titled “Contraband Searches and Environmental Rounds, PC 162” last revised 05/2023, showed that it pertained to the following departments: nursing, housekeeping, clinical services and plant operations departments. The policy addressed staff having proper training to perform contraband checks and noticing and removing dangerous object from patient care areas, including sharp objects and anything with an edge that could be used for self-harm or harm to others. Observation on 7/14/25 at 11:15 am of facility’s adolescent outdoor playground and recreation area showed the following: there was a 9 ½ foot wooden fence surrounding the entire area. The fence had vertical wooden planks along with horizontal wooden planks on the top rim of the fence. On three of the vertical fence planks and on one of the top vertical fence planks, there were oblique/longitudinal cracks in the wood, creating loose triangular large ‘splinters’ which were accessible to patients to remove. The wood was able to be pulled back, broken off, and potentially used as a sharp weapons. Further observation of the fence revealed there were at least two rusty nails protruding approximately two inches from the top planks of horizontal wood planks. These were accessible to patients via climbing internal horizontal wooden support planks by using them as a ladder. These nails had the potential to be manually removed by patients to use for self-harm or to ham others. In an interview at the time of findings, QD Staff #D acknowledged these findings were safety hazards and should not have been present. In another interview at the time of findings, CNO Staff #B also acknowledged that the wooden plank splinters and the rusty nails protruding from the wood were considered contraband and these hazards should not have existed as they were a danger to patients. .”

“Meet Hospital CoPs CFR(s): [Psychiatric hospitals must] Meet the Conditions of Participation specified in§§482.1 through 482.23 and §§482.25 through 482.57; This Standard is not met as evidenced by: 35028 . Based on observation, interview, and record review, the facility failed to ensure that a registered nurse supervised the care of 1 of 1 adolescent patients (Patient #3) as specified in CFR 482.23(b)(3) - A0395 - RN Supervision of Nursing Care. More specifically, the facility failed to ensure that Staff E (RN) followed through with the instructions from an emergency room physician for Patient #3 after he was evaluated in the ER for right flank pain and hematuria [blood in the urine]. Additionally, Staff E (RN) failed to document the hematuria in the medical record after she witnessed it. Findings included: Review of Policy 16821261, “Assess and Reassess, PC 209,” last approved 10/2024 showed: “Departments: Nursing ... Purpose: To utilize the Nursing Process and assess all patients at a minimum of every shift and document findings ...” ***** Patient #3 prior to ER evaluation. Review of “Psychiatric Evaluation” dated 6/6/25 at 8:10am by Staff P, showed: Past medical history - asthma, tonsillectomy, adenoidectomy, right tibial fracture with open reduction and internal fixation. There is no documentation of hematuria. Review of “Patient History and Physical Examination” dated 6/6/25 at 11:07am by Staff V (PAC), showed: Review of systems negative. Physical Examination showed abdomen nontender, nondistended, no palpable abnormality. Lab - pending. Medical history and physical diagnoses: Enuresis [bedwetting] and asthma. There is no documentation of hematuria. Review of Admission Urinalysis dated 6/6/25, 9:00pm, was negative for occult blood. In an interview with Staff E (Charge RN - adolescent boys) on 7/10/25 at 10:35am, she stated that Patient #3 complained of being “punched or elbowed” when he was pulling a patient off Staff F (MHT) during a code. She also stated she saw blood in his urine, adding that the patient was sent to an emergency room for evaluation. During the interview, the “RN Shift Assessment” dated 7/7/25 at 10:07am by Staff E (RN) was reviewed. It showed: Alert and oriented times four [person, place, time, and situation]. Mood irritable. Affect congruent with mood. Denied suicide ideation, homicide ideation, hallucinations. Medication compliant. “Cooperative.” There was no documentation of the nurse witnessing hematuria. She concluded by saying she did not document the blood in the urine. Review of “RN Shift Assessment” dated 7/7/25 at 10:15pm by Staff W (RN), showed: “Patient complained of right flank pain, reported small bloody urine ... vomited earlier during day shift.” Transferred to ER. ***** Documentation from the ER. Review of the “Patient Visit Information” from the Emergency Room dated 7/7/25 by Staff T (ER MD), showed: “Blood in urine ... evaluated for blood in the urine ... [and] trauma to the right flank.” CT and kidney function were normal. “Due to the blood in the urine, please follow up with your primary pediatrician in the next week to ensure resolution of symptoms ... Call your primary care provider within the next 24 hours to schedule a follow-up appointment in the next 2 to 3 days ... Please contact ... Staff U (MD - pediatrician) ...” ***** Patient #3 after ER evaluation. Review of “Reassessment Post Emergency Room Form” dated 7/8/25 at 4:30am by Staff W (RN), showed: Hematuria [blood in urine], Intermittent right flank pain at 5/10. Review of “RN Shift Assessment” dated 7/8/25 at 11:55pm by Staff W (RN), showed: “Complaints of right flank pain.” Given Tylenol. “Reported his urine was still bloody.” Review of “RN Shift Assessment” dated 7/9/25 at 9:30am and 11:11pm and 7/10/25 at 10:49am and 10:31pm by various RNs showed that the patient was not assessed for right flank pain or blood in his urine. Review of “Psychiatric Progress Notes” dated 7/5/25 at 7:40pm by Staff R (NP), 7/7/25 at 11:08am by Staff Q (NP), 7/8/25 at 11:04am by Staff Q (NP), 7/9/25 at 11:21am by Staff Q (NP), and 7/10/25 at 10:24am by Staff Q (NP) showed no documentation of the alleged injury Patient #3 stated he sustained on the night of 7/4/25. The notes did not document an assessment of right flank pain or blood in the urine. There was no documentation of the need for follow-up as recommended by Staff T, the ER physician that evaluated him. All progress notes were co-signed by the attending physician, Staff P. Review of the medical record of Patient #3 on 7/11/25 showed that there had been no follow up on the recommendations of the Staff T, the ER physician who first diagnosed hematuria on 7/7/25. In an interview with Staff B (CNO) on Friday, 7/11/25 at 1:00pm, this finding was discussed with Staff B (CNO). In an interview with Staff B (CNO) on Monday, 7/14/25 at 11:15am, she stated that on 7/11/25, she contacted the physician group responsible for medical consults and requested a medical consultation be conducted on Patient #3 to reassess right flank pain and blood in his urine. She also reported that urine was recollected on 7/12/25, describing it as “cloudy” with “red tissue residue.” She also reported that Patient #3 continued to complain of right flank pain for which Ibuprofen every six hours was ordered. Review of “Medical Consult Notes” dated 7/11/25 at 4:22pm by Staff X (PAC), showed: “Follow up ER visit. Patient sent out ... status post altercation with staff member. Patient was hit in the right flank. Had episode of vomiting and hematuria. Today still complains of pain to right flank. Review of Systems: GU - hematuria. Right flank pain. Assessment: Hematuria. Repeat UA every day to monitor hematuria. Continue Ibuprofen 400mg every six hours prn pain. Follow up upon discharge with PCP if still symptomatic. Follow-up: As needed.” Review of the urinalysis collected 7/12/25, received 7/13/25, and reported on 7/14/25 showed occult blood 2+ abnormal. Review of urinalysis collected 7/13/25, received 7/13/25, and reported 7/14/25 showed occult blood 3+ abnormal. .”

“Maintain Clinical Records CFR(s): [Psychiatric hospitals must] Maintain clinical records on all patients, including records sufficient to permit CMS to determine the degree and intensity of treatment furnished to Medicare beneficiaries as specified in §482.61; and This Standard is not met as evidenced by: 35028 Based on observation, record review, and interviews, the facility failed to maintain clinical records on all patients as specified in §482.61 (Special Medical Record Requirements). More specifically, the facility failed to accurately record progress notes so that a chronological picture of the patient’s progress was given, outlined in A1655 - CFR §482.61(d). This was evidenced by the facility’s failure to ensure that newly disclosed information of an alleged sexual assault by the biological father of 1 of 1 patients (Patient #1) was documented in the progress notes by 4 of 4 staff members - Staff N (Risk Manager), Staff F (Nurse Supervisor), Staff M (Unit RN), and Staff V (Unit RN) - all involved in the investigation of an alleged incident of sexual misconduct on the unit between Patient #1, the alleged aggressor, and Patient #2, the alleged victim. In addition, the facility failed topProvide an accurate recapitulation of the patient’s hospitalization in the Discharge Summary, outlined in A1670 - CFR §482.61(e). This was evidenced by the facility’s failure to ensure that: The Discharge Summary of 1 of 1 patients (Patient #1) included documentation of newly disclosed information of an alleged sexual assault by the biological father, and The Discharge Summary of 1 of 1 patients (Patient #1) included documentation of an alleged incident of sexual misconduct on the unit between Patient #1, the alleged aggressor, and Patient #2, the alleged victim. Findings were: A1655 - CFR §482.61(d) - Recording Progress Notes. Review of policy, “Mental Health Record Content, IM 107,” revised 04/2022 by Staff W (HIM Director), showed: “It is the policy of Kingwood Pines Hospital that all mental health records shall contain sufficient information ... The medical record is a critical medical legal document which must be accurately and concisely compiled, in a timely manner to be an effective tool used to gauge and substantiate the quality of care and service provided to our patients ... The progress notes give a pertinent chronological report of the patient’s course in the hospital and reflect any change in condition and the results of treatment.” Record review of Staff N’s (Risk Manager) interview with Patient #1 showed, “Patient ... reports that as a child she was sexually assaulted by her father ... [and that this] ... has never being [sic] reported.” Review of all progress notes in the medical record of Patient #1 showed that her allegations of sexual assault by her father had not been documented by Staff N (Risk Manager), Staff F (Nurse Supervisor), Staff M (Unit RN), and Staff V (Unit RN) - all involved in the investigation of an alleged incident of sexual misconduct on the unit between Patient #1, the alleged aggressor, and Patient #2, the alleged victim. In an interview with Staff N (Risk Manager) on 02/05/2025 at 12:40 PM, he stated he interviewed Patient #1 on 01/27/2025 at 12:00 PM concerning allegations of sexual misconduct between her and Patient #2. He also stated that during the interview, Patient #1 alleged she had been sexually assaulted by her biological father and had never disclosed this information. Staff N concluded by saying he did NOT document this information in the medical record of Patient #1, adding, “I don’t document in the chart.” In an interview with Staff B (CNO) on 02/05/2025 at 12:42 PM, she stated that Staff N (Risk Manager) can and should have documented his findings of alleged sexual assault by Patient #1’s father in the medical record on the day it was disclosed to him by the patient. She was observed and overheard telling Staff N that he can add progress notes to medical records. Review of the CPS report submitted 01/06/2025 at 5:57 PM by Staff F (Nurse Supervisor) showed: Allegations - Sexual abuse Who is the alleged victim? [blank] Who is the alleged perpetrator? [blank] Sexual abuse was reported by the child. Who else knows about the abuse? “Per patient he is in jail right now.” Primary victim: Patient #1 Further review of the CPS report submitted 01/06/2025 at 5:57 PM by Staff F (Nurse Supervisor) showed that the alleged perpetration by Patient #1’s biological father was NOT documented in the report. On 02/05/2025 at 1:30 PM the CPS report was reviewed with Staff B (CNO). In an interview at that time, she stated the report filed by Staff F (Nurse Supervisor) did not capture all of the information disclosed by Patient #1 of the alleged sexual assault by her biological father. She stated she would resubmit a report to CPS with that information. The revised CPS report submitted to CPS by Staff B on 02/05/2025 at 2:28 PM was reviewed. It contained the information disclosed by Patient #1 of alleged sexual assault by her biological father. In an interview with Staff F (Nurse Supervisor) on 02/05/2025 at 3:02 PM, she stated that Patient #1’s foster mother said she knew about the alleged abuse by the biological father. Staff F also said she filed a CPS report on this and put it in Patient #1’s medical record, adding she did not make a progress note about the alleged perpetration. In an interview with Staff B (CNO) on 02/05/2025 at 1:30 PM, she stated Staff F (Nurse Supervisor) should have documented the alleged abuse by the biological father of Patient #1 in the medical record. In a phone interview with Staff M (RN) on 02/05/2025 at 1:05 PM, she stated she was working as the medication nurse on 01/26/2025, the day of the alleged incident of sexual misconduct between Patient #1 and Patient #2. She said she and Staff V (RN) interviewed Patient #1 and it was during that interview that the patient made an allegation of sexual abuse by her biological father. She also said she spoke with the foster mother that evening, adding that the foster mother did NOT know there were allegations of sexual abuse by the biofather toward Patient #1. She stated the RN Shift Assessments had been divided between her and Staff V, the charge RN, with each having 7 or 8 patients to write notes on. She also stated that Staff V had Patient #1; therefore, it was Staff V’s responsible to write that progress note, adding, “Staff V said she would document it and didn’t.” Staff M did state that the allegation of sexual abuse by Patient #1’s biological father should have been documented in the medical record. Staff B (CNO) was present during the phone interview with Staff M. In an interview with Staff B (CNO) on 02/05/2025 at 1:10 PM, she told Staff M (RN) she was one of two RNs who received the information of alleged sexual abuse by her biofather from Patient #1; therefore, she should have documented the allegation in the medical record. Staff B also stated that it was the responsibility of Staff M to follow up to see that this information had been captured in the medical record. In a phone interview with Staff V (RN) on 02/05/2025 at 1:10 PM, she confirmed that the RN Shift Assessments had been divided between her and Staff M (RN), adding that Patient #1 had been assigned to her. Staff V stated Patient #1 alleged her biological father sexually abused her, adding, “Don’t tell my foster parents.” Staff M also said that the allegation should have been documented in the medical record. Staff B (CNO) was present during the phone interview with Staff V. In an interview with Staff B (CNO) on 02/05/2025 at 1:15 PM, she told Staff V (RN) she should have documented allegations made by Patient #1 of sexual abuse by her biological father. A1670 - CFR §482.61(e) - Discharge Summary. Review of policy, “Mental Health Record Content, IM 107,” revised 04/2022 by Staff W (HIM Director), showed: “”The Discharge/Clinical Summary is a comprehensive summary of the patient’s treatment ... including ... Significant Findings ... Hospital Course of Treatment.” Review of the Discharge Summary for Patient #1 dictated 01/27/2025 at 12:49 PM by Staff X (NP) and signed by Staff C (Attending Physician) showed: An admission date of 01/21/2025. The discharge date was not documented. The alleged sexual misconduct with Patient #2 was not documented. The disclosure of alleged sexual abuse by her biological father was not documented. Review of the Psychiatric Progress Note for Patient #2 by Staff X (NP) dated 02/01/2025 showed that the patient was discharged on 02/01/2025. Further review of the medical record on 02/05/2025 for Patient #2 showed that the Discharge Summary had not been dictated. In an interview with Staff C (Attending MD) on 02/05/2025 at 10:05 AM, he reviewed the documentation in the medical records of Patient #1 and Patient #2 of the incident of alleged sexual misconduct between the two patients. He noted that there was no documentation of the alleged sexual misconduct by the Nurse Practitioners or himself in the Psychiatric Progress Notes and/or the Discharge Summary. He stated that he “probably should have put it in the notes,” adding that it was “an omission on my part.” Additionally, Staff C acknowledged the importance of an accurate recapitulation of the patient’s hospitalization in the Discharge Summary for continuity of care should the records be requested by another facility and/or providers.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 35028 Based on interviews and record reviews, the facility failed to guarantee incidents of abuse and neglect were reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurred. This was evidenced by the facility’s failure to ensure that: The disclosure of recent allegations of sexual abuse and neglect by 1 of 3 patients (Patient #1) were fully assessed and then reported to the appropriate agencies or authorities by an Intake RN, Charge and Staff RNs, Attending Physician’s Nurse Practitioners, and the Attending Physician. Findings were: Record review of Policy 16799145, “Identifying and Reporting Abuse, Neglect, and Sexual Exploitation, PR-102” last approved 10/2024 by Staff D (Chief Nursing Officer), showed: “Purpose ... To establish guidelines for identifying and assessing possible victims of abuse, neglect, or sexual exploitation, whether occurring outside the hospital or in the hospital ... To establish procedures for reporting suspected abuse, neglect, or sexual exploitation to Children’s Protective Services ... of the Department of Family and Protective Services, and Texas Health and Human Services ... Staff shall be alert to physical, behavioral, or other evidence of abuse, neglect, or sexual exploitation at each stage of the admission process ... Members of patient’s treatment teams and other hospital staff members shall be alert to physical, behavioral, or other evidence of abuse, neglect, or sexual exploitation of patients that occurred outside the hospital ... Behavioral evidence of abuse, neglect, or sexual exploitation ... Inadequate ... supervision of a child, adolescent ... Action by staff suspecting abuse, neglect, or sexual exploitation of patients that occurred outside the hospital ... the staff member shall promptly notify the Chief Nursing Officer, and, in the case of admissions staff members, the Director of Admissions. The staff member shall report the suspected abuse, neglect, or sexual exploitation to the Child Protective Services ... or Department of Family and protective Services ...” Patient #1. Record review of the “Intake Assessment Tool” by Staff R, an RN in the Intake Department, dated 12/2/2024 at 6:35 pm, showed a 16-year-old female voluntarily admitted into the hospital with suicidal ideation and a plan to ingest methamphetamines laced with poison or to cut her wrist. During the assessment, the patient, accompanied by her mother, stated: (a) She had a history of sexual victimization within the previous 6 months as indicated by having sex with multiple people for drugs. (b) She tried to kill her sister with [a piece of] glass 2 to 3 weeks earlier. (c) She ran away from home 3 months earlier. (d) She had irritability, poor impulse control, physical and verbal aggression, and difficulty with sleep. (e) She had a history of sexual trauma, sexual assault, sexual victimization. (f) She was smoking 1 gram of methamphetamines daily since age 14 with the last use on the morning of admission. (g) She used marijuana daily with the last use on the morning of admission. (h) Her mother had a history of depression suicide attempt, intense mood swings, hallucinations, delusions, and prior psychiatric hospitalization. Further review of the “Intake Assessment Tool” showed that Staff R did not further investigate the allegations of sexual trauma, sexual assault, sexual victimization. Staff R did not report the recent sexual assault and victimization (engagement in sex for drugs) to the Department of Family and Protective Services. Additionally, Staff R documented on the form that the abuse and neglect (engagement in sex for drugs) was NOT reported to the Department of Family and Protective Services. In an interview with Staff R on 1/8/2025 at 12:05 pm, she stated that the allegations of abuse and neglect made by Patient #1 should be reported to the Children’s Protective Services. She also stated that even though she documented the abuse and neglect had NOT been reported to the Department of Family and Protective Services, she DID report it. Shortly thereafter following considerable time trying to locate the report, she stated she was not able to find the report in her files. Record review of the SBAR (Situation, Background, Assessment, Recommendation) form by Staff V (RN) dated 12/2/2024 at 8:35 pm (completed 2 hours after the Intake Assessment) showed: High risk areas - suicide, assault, elopement ... sexual acting out (victim) ... self-harm ... Client endorses sexual abuse by several people ‘in trade for drugs’ ... Has been coerced into sex with multiple people in trade for drugs.” Staff V did not document that the allegations of sexual abuse in trade for drugs were reported to Child Protective Services. Record review of the Staffing Schedule for 12/2/2024 showed that Staff Q was the RN on Unit 600. Record review of the “Nursing Admission History” by Staff Q (Unit 600 RN) dated 12/2/2024 at 11:00 pm (completed 4½ hours after the “Intake Assessment Tool”) showed NO history of sexual victimization within the previous 6 months. This documentation was not congruent with the documentation on the “Intake Assessment Tool,” which affirmed a history of sexual victimization within the previous 6 months. Staff Q did not document that there was further investigation of this incongruent information. Staff Q also documented a history of sexual aggression over the lifetime of Patient #1 but did not document the name of the victim as was prompted by the form. And lastly, Staff Q documented psychological trauma but failed to provide additional information even though the form prompted the nurse to do so. In an interview with Staff C (Assistant Chief Nursing Officer) on 1/8/2025 at 11:38 am, she stated that if a patient tells the nurse that there’s a history of sexual abuse, the nurse should further assess this by asking more questions and documenting the history. She also stated that other staff should be updated as new information is obtained about sexual abuse. She also stated: 1) Staff R (Intake RN), who documented that Patient #1 was a sexual victim, should have assessed further and documented that information. 2) Staff Q (Unit 600 RN), who documented a history of sexual aggression and a history psychological trauma - sexual abuse, should have “asked more questions. The nurse didn’t do a thorough assessment.” 3) Staff N (Attending Physician) “didn’t catch it either.” She concluded the interview by saying, “It was missed by 3 people. Allegations of sexual abuse by a child must be reported to the State.” Record review of the “Psychiatric Evaluation” by Staff N (Attending Psychiatrist) dated 12/3/2024 at 9:40 pm showed, “She [Patient #1] said that she feels despondent because of escalation of her methamphetamine use and has been self-harming and quite desperate to get a hold of her substance use, which she thinks is getting out of hand.” He noted that the patient lives with her mother and will “discharge home to her family upon resolution of her symptoms.” Further review of the “Psychiatric Evaluation” showed that there was no documentation of a history of sexual victimization, sex with multiple people for drugs, sexual acting out (victim), or sexual abuse / coercion for sex by several people “in trade for drugs.” Record review of the Psychiatric Progress Notes by Staff W or Staff X, both Nurse Practitioners, dated 12/4/2024 at 11:44 pm, 12/5/2024 at 11:47 pm, 12/6/2024 at 11:02 pm, 12/7/2024 at 9:38 pm, 12/8/2024 at 12:02, 12/9/2024 at 11:14 pm, and 12/10/2024 at 11:56 pm showed that there was no documentation of a history of sexual victimization, sex with multiple people for drugs, sexual acting out (victim), or sexual abuse / coercion for sex by several people “in trade for drugs.” The supervising psychiatrist on each Progress Note was identified as Staff N. In an interview with Staff E (RN on Unit 600) on 1/7/2025 at 9:59 am, she stated that if a patient reported sexual abuse, she would “send it up the chain” by reaching out to the charge nurse. Record review of the Discharge Summary by Staff W (NP) and co-signed by Staff N (Attending Psychiatrist) dated 12/10/2024 at 11:42 pm showed that there was no documentation of a history of sexual victimization, sex with multiple people for drugs, sexual acting out (victim), or sexual abuse / coercion for sex by several people “in trade for drugs.” Discharge Disposition: Discharged to home. Record review of the “Discharge Summary Plan” by Staff Y (LMSW) dated 12/10/2024 at 1:46 pm showed: Discharge Disposition - Home with mother. Record review of the E-Report to the Texas Department of Family and Protective Services, authored and submitted by Staff S (Licensed Master Social Worker) dated 12/4/2024 at 3:21 pm, showed two alleged perpetrators: 1) Patient #1’s mother 2) The man who allegedly gave Patient #1 substances for sexual favors. The man was identified by name. Patient #1 stated she “had access to go to his home when she wanted,” adding he is “currently booked in jail.” Staff S also wrote, “Child has multiple substances (reported meth, marijuana, alcohol) and engaged in sexual acts with male perpetrator.” Staff S stated the mother provided “neglectful supervision,” adding, “Patient was left unattended to go to sexual perpetrator’s house and was not properly supervised by her mother.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 43549 Based on observation, and interview the facility failed to maintain a safe setting in patient rooms as evidenced by the presence of shower stalls with flaked paint, wall board and /or tile in rooms for 7 of 10 rooms observed (#s 103, 105, 106, 107 ,108, 110 and 111). Additionally patient bedrooms with missing caulking to seal the floor tile in the personal showers of 11 of 13 rooms observed (#’s 407, 411, 412, 413, 607, 608, 609, 610, 612, 614 and 615). During a tour of the facility 4/29/24 at 11:25 am with Staff #8 Clinical Nursing Manager several rooms on the second floor were observed. Observations during the tour were: Room 407 Rusty bottom, wall heating/ air conditioning (A/C) unit Rust falling off in flakes, sharp edges on sides, chipping paint. Room 411 Rusty bottom, wall heating/ air conditioning (A/C) unit Rust falling off in flakes, sharp edges on sides, chipping paint. Room 412 Rusty bottom, wall heating/ air conditioning (A/C) unit Rust falling off in flakes, sharp edges on sides, chipping paint. Room 413 Rusty bottom, wall heating/ air conditioning (A/C) unit Rust falling off in flakes, sharp edges on sides, chipping paint. Room 607 Rusty bottom, wall heating/ air conditioning (A/C) unit Rust falling off in flakes, sharp edges on sides. Shower stall calking missing/ shrink causing gap between floor and wall. Room 608 Rusty bottom, wall heating/ air conditioning (A/C) unit Rust falling off in flakes, sharp edges on sides. Shower stall calking missing/ shrink causing gap between floor and wall. Room 609 Rusty bottom, wall heating/ air conditioning (A/C) unit. Shower stall calking missing/ shrink causing gap between floor and wall. Room 610 Wall heating/ air conditioning (A/C) unit Rust sharp edges on sides. Shower stall calking missing/ shrink causing gap between floor and wall. Room 611 Wall heating/ air conditioning (A/C) unit Rust sharp edges on upper surface and sides. Room 612 Wall heating/ air conditioning (A/C) unit Rust sharp edges on sides. Shower stall calking missing/ shrink causing gap between floor and wall. Room 614 Extremely rusty and corroded rusty, wall heating/ air conditioning (A/C) unit rust falling off in flakes. Room 615 Wall heating/ air conditioning (A/C) unit Rust sharp edges on sides. Shower stall calking missing/ shrink causing gap between floor and wall. When interviewed 4/30/24 at 11:50 am, Staff #5 Director of Plant Operations stated he does environmental rounds monthly along with the maintenance technicians. He stated he looks for walls that need to be painted including touch-ups and torn mattresses. He stated they have not been looking at room in wall heating/ air conditioning (A/C) units or shower tiles and confirmed the multiple rusty in wall heating/ air conditioning (A/C) units and missing shower tile caulking.”